As thousands more Arkansans test positive for COVID-19 each day and the number of available intensive care unit beds in the state’s hospitals dwindles, the University of Arkansas for Medical Sciences is beginning the next phase of its surge plan.
In an email sent Wednesday morning to employees and students, UAMS leaders laid out dramatic new measures to manage the crisis, including a plan for ICU nurses at UAMS Medical Center to take on more patients than they would under normal circumstances.
Because critical care patients require constant monitoring and attention, ICU nurses typically care for only one or two patients each. In the coming weeks, UAMS will likely increase the ratio of patients per nurse by rolling out a “team-based care model.” The hospital plans to bring non-ICU nurses into the unit to serve as support for regular ICU nurses, allowing the ICU nurses to take on three or even four patients each if needed.
In previous interviews with the Arkansas Nonprofit News Network, some doctors and nurses have warned that an increase in hospital staffing ratios could lead to worse care for patients, more burnout for medical providers and, ultimately, more deaths. But as the caseload keeps growing, hospitals may have little choice but to make their staff take on more patients.
Hospitalizations in the state reached yet another record high of 1,195 on Thursday, according to the Arkansas Department of Health — more than twice as many as during the height of the summer wave.
The UAMS email, which was sent by Chancellor Cam Patterson and Vice-Chancellor Steppe Mette, also describes other components of the hospital’s plan. Some registered nurses who do not typically work in patient care will begin serving shifts in the hospital. Emergency room patients will be screened in a “triage area” to be constructed in a parking garage next to the ER. Telemedicine use will increase, some elective procedures will be rescheduled, and more patients who underwent surgery will be sent home without an overnight stay.
Patterson outlined the changes Wednesday morning in a series of public tweets. UAMS is not alone in having difficulty keeping up with the soaring COVID caseload, the chancellor said.
“In my conversations with other hospital leaders across the state, I am hearing similar stories,” he wrote, noting that the UAMS College of Public Health had projected just such a situation. “Unless circumstances change drastically, this will get worse before it gets better.”
In an interview Thursday, Mette, who is also the CEO of UAMS Medical Center, said he anticipates the hospital will need to begin using the team-based model within “the next week or two” because of unceasing demand for ICU beds.
“It has not been implemented, but we are poised to do so,” Mette said. “We have the structure in place.”
UAMS typically has 52 ICU beds. In recent months, it has added 12 more by converting beds from the hospital’s progressive care unit, which is an intermediate step between the ICU and the hospital’s general medical wards.
The hospital is now looking to add another 18 ICU beds. However, that would make it impossible to maintain the ICU’s normal two-to-one staffing ratio, Mette said, forcing the hospital to begin using the team-based approach.
“As soon as we hit that point where we can’t promise safe staffing, that’s when we need to implement it,” Mette said.
ICUs require low staffing ratios to operate safely because their patients are the sickest of the sick. “Picture a patient who is on a life support machine, who is on multiple intravenous infusions, catheters everywhere, monitors everywhere, and the patient can change condition very quickly,” Mette said. “It requires the full attention of the team. The ICU nurse is really that point person that provides moment-to-moment care. … You can’t dilute the attention of the nurse with multiple patients.”
The nurses who will serve as support in the ICU are coming from various other places within UAMS, Mette said, mostly from outpatient clinics. “Some have had many years of nursing care experience, but now are in administrative roles, for instance,” he said. Under the team-based model, Mette said, those nurses will take on less skilled tasks in the ICU, allowing the experienced ICU nurses to focus on tasks that require more specialization and training.
As of Thursday afternoon, Arkansas hospitals had just 56 ICU beds available out of 1,155 statewide, according to a daily report from the health department. COVID patients occupied 397 of those ICU beds, more than one-third of the total. ICU occupancy fluctuates from hour to hour, and some regions of the state have had no available ICU beds at all at certain points in recent weeks.
“This move on our part … is really in preparation for what we see coming down the pike,” Mette said.
One doctor who works at multiple hospitals in Central Arkansas said she understood why UAMS was moving toward a team-based approach. “I don’t see that there is another option,” she said, given the volume of patients.
But the doctor, who asked that her name be withheld for this article, said she had concerns. “There are certainly parts of the nursing job that can be done by someone who is not critically care trained,” she said. “However, the COVID-positive patients are more labor intensive than the typical ICU patient.”
Very sick COVID patients often have other health conditions that require close monitoring of medication, she said. Nurses have to suit up in personal protective equipment before entering a COVID patient’s room, taking up precious time. “You would want to actually change the ratio to allow the nurse to devote more time to each patient, not less,” she said.
“ So, if a nurse has three or four really sick COVID positive patients, no. There is zero way that that will be done without compromising the quality of care,” she said.
Mette said UAMS implemented the first phase of its surge plan about two months ago, when it began performing fewer elective surgeries.
“We reduced that number as our first attempt to create capacity, and what we’re doing now is our second phase,” he said.
The ICU isn’t the only place at UAMS where things will change in the coming weeks. Registered nurses who are no longer in direct patient care roles can also volunteer to work as “COVID-extenders” in other parts of the hospital.
Most hospitalized COVID patients at UAMS are not sick enough to require care in the ICU and are kept in negative air pressure rooms on a separate floor of the hospital. (Mette said UAMS had a total of 59 COVID patients as of Thursday morning, 16 of which were in the ICU.) COVID-extenders will work in these non-ICU settings.
The hospital also may begin placing non-critical COVID patients two to a room, a departure for the hospital. UAMS has had only private rooms for the past decade, Mette said. “We purchased or rented beds back in the fall because we knew this was likely to happen,” he said.
Andrea Peel, a spokeswoman for UAMS, said almost 40 nurses had answered the call to potentially serve as either COVID-extenders or support for ICU staff. The actual number of employees used for these new roles will depend on the number of COVID hospitalizations, she said.
Mette said UAMS has been careful to avoid creating holes in other parts of the hospital as it shifts workers within the facility. Rescheduling surgeries that are not time-sensitive has helped free up some staff, he said.
“For instance, in our operating rooms or our procedure rooms, if we recognize that there are procedures that could be done in two months rather than tomorrow, we might cut back on those. The same goes for routine outpatient visits. … But we’re not going to rob Peter to pay Paul for patient care,” he said.
Mette said some patients who would normally be kept overnight following a routine elective procedure, such as a knee or hip replacement, may be sent home earlier. With proper training for family members or professional caregivers, he said, many patients can safely avoid staying in the hospital after such surgeries.
As one of the largest hospitals in the state, UAMS receives many critically ill or injured patients from small and midsize facilities across Arkansas. Now, it is working to cut down on the number of transfers by providing care for more patients remotely, Mette said.
The hospital has long treated certain stroke and trauma patients through telemedicine, he said. “We’ve got lots of experience with it — we’re just expanding the scope of what we do.”
Large medical centers like UAMS are likely to receive more transfers of COVID patients from smaller hospitals in the weeks ahead. On Dec. 16, the state began using its new “COVID-Comm” system, which builds upon the existing statewide Trauma Communications System to more efficiently direct COVID patients to available beds. But so far, the larger hospitals haven’t had room to receive many patients in need of a transfer.
“On our end, we have been so full that we have not been able to take many of the requests,” Mette said. As large Central Arkansas hospitals implement their surge plans, they should be able to take in more patients, he said. “I know that Baptist, UAMS and St. Vincent’s are working on that.”
UAMS will soon begin constructing an outdoor triage area in a parking garage attached to its emergency room. Mette said the emergency department has seen a “dramatic increase” in visits, much higher than over the summer, often creating a backlog. At one point recently, he said, “we had 14 patients who needed inpatient beds. They were officially admitted, but we had no beds in the hospital to send them to.”
Some of those patients have waited for nearly a day for a bed to open up, he said.
The ER triage facility, he said, would allow for better assessment of patients: “Do they need immediate care? And if so, do they need ICU level care or less time-sensitive care? Or can they wait longer — can they be taken care of as an outpatient?”
In addition to expanding hospital capacity, UAMS continues to test hundreds of patients each day in its drive-through testing center. It is using two types of monoclonal antibodies to treat some high-risk patients with mild to moderate symptoms on an outpatient basis. And UAMS has been vaccinating its employees as quickly as possible: In December, it delivered shots to almost 3,500 workers out of about 5,000 who are in the first tier of eligibility.
“We used up our entire supply of vaccine before Christmas and have been waiting for the next shipment, which arrived yesterday,” Mette said on Thursday. A group of about 2,000 front line workers should receive their second dose of the two-shot regimen next week, he said.
Still, there is little that UAMS can do to slow the spread of the virus in the community, other than issue warnings to a public that seems increasingly weary of the pandemic. Patterson tweeted on Wednesday that “you can help us by thanking those who work in healthcare for the work that they are doing under these difficult circumstances, & more importantly abiding by the principles of masking & social distancing.”
Cases continue to rise. On Thursday, 2,708 people tested positive for the coronavirus in Arkansas, bringing the state’s number of active cases to 22,189.
The anonymous Central Arkansas doctor said the state should impose a shutdown order. “The governor would say ‘Well, there’s no proof that these restrictions are needed.’ My counter to that is, well, the proof is in the dead bodies,” she said.
Thirty-nine more people died of COVID-19 related causes in Arkansas on Thursday, bringing the state’s death count to 3,676 since the pandemic began.
Shutdowns, the doctor said, have proven effective at slowing the spread of the virus. “When we did it in the spring, our numbers started going down,” she said. “I one hundred percent understand that the economy will suffer tremendously, but in my mind it’s this government’s job to figure out how to mitigate that blow in order to save lives.”
“There is just a tremendous sense of denial happening here,” the doctor said.
This reporting is courtesy of the Arkansas Nonprofit News Network, an independent, nonpartisan news project dedicated to producing journalism that matters to Arkansans.